On-line version ISSN 2078-5135Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.102 n.5 Cape Town May. 2012

The nursing supervisor of a Rondebosch frail care annexe and two nurses who failed to follow or record explicit doctor instructions to halve a warfarin dose and stop administering sedatives to a vulnerable 91-year-old were suspended last month - more than 3 years after the offence.

Mrs Madge Morkel, discharged from Kingsbury Hospital to the Gordon Greene Annexe of the Fairmead Retirement Home, on 13 June 2008, died of acute liver failure 8 months later, causing the Nursing Council's Professional Conduct Committee to speculate as to whether the dismal care she received contributed to her death. Annexe Supervisor, Mr Fikile Caleni, of Crawford, a registered nurse with psychiatry, community and midwifery qualifications, was suspended by the committee for 2 years, this sentence suspended conditionally for 3 years. He was found guilty of improper and disgraceful conduct in that he 'wilfully or negligently' failed to carry out acts in respect of collaborating, co-ordinating and advocating for the care of the patient, failed to keep clear and accurate records of all actions performed and failed to administer medication as prescribed.

Annexe manager 'unapologetic

Unlike the two long-serving nurses whom the Nursing Council decided to prosecute, (Michelle Finnies of Zeekoevlei found guilty of the first two charges above and Sister Magdalene Thai, of Steenberg, found guilty of all three charges above), Caleni expressed neither regret nor proffered apologies to Mrs Morkel's two daughters. He had a long-standing adversarial relationship with both daughters, Mrs Jeanne Welsh and Mrs Marichien Schimmel, who, after a litany of complaints, succeeded in having the Cape Peninsula Organisation for the Aged (CPOA) remove him from his post and placed elsewhere. Caleni accused them of 'trying to undermine him' by complaining (inter alia) that their mother was seldom bathed, smelt of urine and that a foul-smelling wound on her leg went unnoticed and untreated (requiring plastic surgery). A 03h40 fall from her bed on 8 June 2008 in which she broke 3 ribs was reported to them (only), more than 7 hours later, they testified. A paucity of evidence led to the Nursing Council acquitting the accused trio of failing to create a safe environment for Mrs Morkel and failing to inform her doctor when her condition worsened. The nurses were, however, each suspended from practising for 2 years, this sentence suspended for 2 years. The trio had pleaded not guilty to all charges.

Committee chairperson and head of the nursing school at the University of KwaZulu-Natal, Professor Busisiwe Benghu, apologised to the Morkel family (and the public at large) on behalf of the Nursing Council, saying nurses were 'supposed to monitor, care and advocate' for their patients. She commended the Morkel daughters for 'coming forward', saying global literature indicated that families were generally not informed of adverse events. She added that she 'hoped' other family members of the elderly and vulnerable would learn from their example. When promised standards were not delivered, the public should be offered 'an apology, a full explanation and a speedy and effective remedy'. Professor Benghu said it was 'most disturbing' to find a family taking the initiative for patient care rather than the professionals employed to do so. (The two daughters employed a private caregiver to bathe, monitor and care for their mother after losing faith in staff at the home, as did other relatives of patients at the home). At the time (2008), the Fairmead Annexe was charging its frail-care residents R8 805 per month.

Alarming INR levels

The committee heard that Mrs Morkel, who was in the early stages of senile dementia, was admitted to hospital three times, each time receiving plasma and blood transfusions. After Kingsbury Hospital treatment (for broken ribs, underlying pneumonia and a blood INR count of 10) began on 8 June 2008, she was discharged on 13 June, her doctor having reduced her prescription of 5 mg warfarin to 2.5 mg with instructions to halt any warfarin dosage on that day plus all sedatives until further instructions. The daughters said they took the new prescription to Caleni, reading it through with him and confirming with him that 2.5 mg warfarin meant half a pill, handing him the script with the full instructions. However, a week later the daughters noticed that their mother's INR levels were again nearly 5 times higher than normal. They confronted Caleni who denied any overdosage. He claimed that although he was off-duty on the weekend of 7/8 June, he had passed on the new drug prescription instructions to his colleagues, telephoning Sister Thai (who told an earlier CPOA hearing she couldn't remember the call). Both nurses declined to take the stand at the council hearing but told an earlier CPOA enquiry that, not having any new prescription to go by, they continued the full warfarin dose for 4 days, recording it as such. The committee heard (via the earlier enquiry) that after coming on duty that Monday and speaking to Mrs Morkel's family, Finnies simply wrote 'new prescription' in the medical record.

The previous day, Sister Thai had initially forgotten the night sisters' injunction to inform the family of Mrs Morkel's fall. At the CPOA hearing, Caleni produced patient medication records for May instead of June in what Mrs Morkel's daughters claim was a deliberate attempt to mislead (a half-dose of warfarin was recorded on identical days in May).

In an anxious letter addressed to the CPOA head office as early as 10 October 2007, Dr Alan Wood described his patient Mrs Morkel's situation as 'intolerable' and needing prompt attention. He expressed concern at her level of care, explaining that she had been 'living very happily at Fairmead Court' when it became unsafe because of her declining cognition and ability to self-medicate. Her INR went up to 8.8 and she ended up in hospital needing transfusion. As a result of this, she was moved to the Annexe so that she could have her tablet-taking supervised. Unfortunately the (mal)administration of the tablets continued - without monitoring of the INR - and Mrs Morkel again required ICU admission and 6 units of blood, he wrote.

Complaints mounting up

Mr Frans Nkosi, who led evidence for the Nursing Council, confirmed that complaints against Mr Caleni by relatives of another former Annexe resident, the late Mrs H Mulock-Houwer, would result in a hearing early next year. The complaint, which predates the Morkel case by over 3 months, centres on alleged rough handling by staff and massive bruising found on Mrs Mulock-Houwer's upper arms and a serious gash on her forearm.

Her daughter, Mrs Fenja Clarke of Newlands, says her mother, then 91, was 'terrified' of the nursing staff and claims Caleni not only intimidated her private caregiver, but failed to properly probe the cut when reported, failed to ensure proper reporting or call a doctor, and failed to ensure staff were adequately trained to enable the handling of patients without causing injury. Nkosi told Izindaba that it was 'not normal' for nursing professional conduct matters to take so long to be heard but 'legal wrangling' in 2008/2009 over whether council could proceed with cases while regulations on the new Nursing Act were being promulgated was to blame. A misplaced file was responsible for Mrs Clarke's case not having been heard beforethe Morkels'. Asked whether the Nursing Council ever reported matters for criminal follow-up to the SA Police Services, he said only when non-nursing-related matters such as fraud were involved. 'We only work in terms of the Nursing Act - there's no legal obligation upon us to report matters to the SAPS; that should come from the aggrieved party,' he said.

Mrs Welsh expressed displeasure at the 'light sentencing of Mr Caleni in comparison with the two nursing sisters he tried to blame for his negligence.' The hearing of Mrs Clarke's complaint early next year however gave her 'some hope' that justice would eventually prevail.

Mrs Pat Lindgren, the founder of Action on Elder Abuse, the only NGO in South Africa dedicated to countering elder abuse, said the Older Persons Act as amended in 2010 made abuse of anyone over 60 years old a criminal offence and put a legal obligation on any witness to report it. It also created an 'abuser' register which prevented anyone convicted of elder abuse from ever working with the elderly or managing a facility for the elderly again. Elder abuse, whether familial or institutional, was often called 'the secret crime' because it was either not witnessed or kept under wraps. Mrs Lindgren said there has been a recent increase in reported elder abuse in South Africa. 'Abuse is normally by somebody who has some form of power over the elderly person - the more dependent you are, the more vulnerable,' she added.

Dr Mark Sonderup, acting chairperson of the South African Medical Association (SAMA), said medical prescriptions had the standing of a legal order. Any doctor who suspected neglect or abuse of an elderly patient should ask themselves the question, 'If it was a 5-year-old what would I do? -They probably wouldn't hesitate to report to a child protection agency. Perhaps that's where we fall short. These things should be reported to social agencies. Sometimes it's easier to access them when your patient is in hospital - but a plan can always be made.'